We are looking for a Māori nurse for this working party, you’d be great…

Sorry to wake you up, but Mrs Toleafoa from down the street has had a turn…

Few nurses see their profession as just a job. But the expectations placed on Māori and Pacific nurses by themselves, their employers and their communities can make an already demanding profession even more challenging.

This is particularly true now, when health strategies stress the need for more Māori and Pacific nurses to help counter poor Māori and Pacific health statistics, while the percentage of Māori and Pacific nurses still lags far behind the actual populations (see statistics sidebar).

Dr Lisa Stewart

So there are too few nurses and too much need. How does this impact on Māori and Pacific nurses? And how do they cope?For her PhD thesis, organisational psychologist Dr Lisa Stewart looked at whether the occupational stress experienced by Māori health workers was different from their mainstream counterparts.

She says two themes emerged, one being the cultural expectation from Māori communities – shared by Pacific communities – that Māori nurses and other health workers give back to the community in some kind of service. The second was institutional racism – often caused by misunderstandings and a lack of cultural competence – which added to Māori health workers’ stress loads.

Community expectations

Māori and Pacific are not the only cultural groups where community and family expectations outside of work are important, says Stewart. But that cultural expectation is very real.

Kerri Nuku

She recalls as a young university student in the 1980s being told by Māori student association leaders that, on graduating, Māori students like herself should help their whānau, hapū and iwi in some way, be it serving on the marae committee or helping out at kohanga reo.

Kerri Nuku, kaiwhakahaere of Te Rūnanga o Aotearoa NZNO, agrees and says being a nurse within a whānau group can lead to additional expectations.

“You will be the contact person for aunty down the road who is not really sure whether she should rock on down to the doctor’s or just put a bandage on it,” says Nuku. “We hear stories of nurses, particularly who work in rural communities with high population Māori, that in the supermarket people come up to you when you are trying to do your shopping at the weekend and ask you for your advice because you are whānau, because you are Māori and because you are approachable.

Jackie McHaffie

“Then if you’ve got somebody sick within the whānau, you go to work, do your work and then come home and take over your shift caring for the sick whānau member. You build your own roster around them so that caring doesn’t stop when you leave the hospital grounds or workplace.”

This sense of duty begins as nursing students, believes Jackie McHaffie, who is in charge of the Tihei Mauri Ora stream of Wintec’s bachelor of nursing programme and has been involved with the programme for around 15 of its 25 years.

“There’s a cultural component that is always going to be there and will add to your duties above and beyond being a registered nurse.
They try and give as much as they can back and in doing so they often burn out.”

Dr Sione Vaka

Dr Sione Vaka, Tonga’s first male nurse, who is now a lecturer for Massey University’s School of Nursing, says likewise there is an expectation from the Pacific community for nurses to deliver as much support as they can. For him this means that in addition to his day job he is on the executive of the Tongan Health Society; he’s also vice-president of the Pacific Island Mental Health Professional organisation, chair of his church’s health committee, a member of both the Tongan Nurses Association of New Zealand and the Aotearoa Tongan Health Workers Association, informal mentor to Pacific postgraduate students from a variety of institutions, feedback provider on Pacific mental health research – and he also holds various other community service positions. And this is all after cutting back his out-of-work commitments to fit his targeted areas of expertise.

Eseta Finaua

Workplace expectations and institutional racism

Then there are the workplace expectations that can be placed on a scarce and already stretched thin Māori and Pacific nurse workforce.

Stewart says one of the stress issues unique to Māori that emerged as a theme during her research (which assessed the work stress levels of 130 Māori health workers, including nurses) was institutional racism; for example, workplaces playing lip service to the Treaty of Waitangi and related policies aimed at improving health outcomes for Māori.

And Stewart says when organisations do recognise bicultural responsibilities – like holding a powhiri to welcome new graduate nurses – non-Māori managers can see this as a Māori-only role, adding an extra layer to Māori nurses’ workloads.

She says it doesn’t have to be that way. A positive example was an organisation she worked at where it was clearly expected that a Māori staff member would lead the karanga but all ethnicities and nationalities were invited to be part of the waiata group that performed support songs and helped set up the powhiri, including food if that was involved.

McHaffie adds that Māori nurses who work for organisations where they may be one of the few or only Māori can find themselves approached for advice on all things Māori, as well as being expected to say the karakia or sing a waiata. But there are also high cultural expectations placed on Māori who are working for Māori providers, which can extend the working day and week for Māori if they need to attend hui or practice for iwi cultural events. Then on top can come expectations for postgraduate study. McHaffie says that over the years she has seen some graduates burn out after struggling to cope with the pressure to be not only a good nurse but also a good Māori nurse.

Nuku says she’s also heard of hospitals placing Māori new graduates in particular units or wards well known to be “not conducive to Māori … oh I will just put it out there… they are areas known to be racist” in the hope of trying to change the behaviour of the staff. “So these are conscious decisions that are being made that put our nurses in unsafe places because nobody has dealt with the issue of racism.”

Nuku and her NZNO colleague Eseta Finau, who heads the Pacific Nursing Section (PNS), also both receive reports of interview processes and panels that are seen as discriminatory and demoralising for Māori and Pacific nurses.
Finau says an ongoing issue for many Pacific-trained registered nurses is being used as “cheap labour” by rest homes while struggling to afford time off to attend the English language training they need to become registered in New Zealand.

Another workplace expectation often adding to the stress loads of already stretched nurses is the belief that Māori and Pacific nurses should be allocated the Māori and Pacific patients, without the workload impact being considered.

“Why are Māori patients the sole domain of Māori nurses and why are Tongan patients the sole domain of Tongan nurses? Aren’t all patients the domain of all nurses?” asks Stewart.

Vaka echoes this, saying sometimes non-Pacific nurses are keen to transfer the care of a Pacific patient to a Pacific nurse, saying they would do a better job.

He believes it is important to encourage other nurses to be comfortable and confident in working with Pacific people, rather than trying to refer all patients to a potentially already overloaded Pacific nurse or Pacific health service.

Not a burden

Community, and employer, expectations may be high of Māori and Pacific nurses but often so are the nurses’ expectations of themselves in doing their best to improve the health outcomes of their people.

Stewart says Māori and Pacific nurses don’t usually see this work as a burden but more a natural extension of being part of a community. “I find when I’m giving back to a really good cause – and I’m helping the whānau in some way – as much as that’s work, it also feels really, really good and has a way of energising you too.”

So giving can be good – it’s over-giving that can be the issue.

Finau says family upbringing is also a major influence, with multitasking just something you do when you’re from the Pacific. “Because at home you grow up with so many kids around, there are family things and church things … and you just learn to juggle and cope with things. Giving back to the community is just another thing you take on and being a nurse you manage your time.”

Stewart’s research found that occupational stress was not lower in kaupapa Māori health providers than in mainstream providers – on the contrary, role overload and organisational constraints were all higher. But the coping strategies were better, which matched earlier research findings (see retention sidebar) that the top factors encouraging Māori health workers to stay with a health provider included being able to make a difference to Māori health and to their iwi or hapū, and that Māori practice models and approaches were valued.

Nuku agrees, saying Te Rūnanga o Aotearoa used to see nurses shifting from Māori provider groups to DHBs because of the money, but, despite pay parity being an ongoing issue (see sidebar), she says the reverse is also happening. “What we are feeling is that there is a trend that they are going back because they can’t cope with the amount of racism that is happening in workplaces.” There is also a frustration that poor Māori health statistics are used as “a patu [weapon] against ourselves”; innovative strategies that do work don’t get sustainable funding; and the Māori nursing workforce is still static, despite strategies aimed at boosting recruitment and retention.

“I don’t think we have looked enough at how we support Māori and Pacific nurses in the workplace,” she says.

Cultural competence of all staff important

One step in the right direction, believe many, is placing value on cultural, as well as clinical, competence in the workplace.

“If all of our nurses were culturally competent to deal with all of the cultural groups that they see in their practice, then the burden of being responsible for Māori patients becomes everybody’s responsibility – not just Māori nurses’ – and Tongan patients are not only the responsibility of Tongan nurses,” says Stewart.

Vaka says he is aware, through non-Pacific nursing friends, that some have a fear they will do something wrong when caring for Pacific patients, so they look to transfer them when possible. He agrees a better approach is for all nurses to upskill themselves culturally, seek advice and “have a crack” themselves in looking after Pacific people.

“If we are able to learn more about one another and how to work with different cultures – it is such a diverse community that we are living in at the moment – it would be improving our overall health care as well,” he says.

Stewart also believes the handover of patients to Māori or Pacific nurses is not intentionally malicious but more a lack of understanding and a lack of confidence in being able to work effectively with those client groups. “The reality is that as a Māori when I go into a health service would I prefer to work with a Māori member of staff? Sometimes I would, but I know the reality is that I won’t. But what I do expect as a Māori health user is that when I use the health services I get treated with dignity and respect in the same way that every other cultural group would expect to be.”

Nuku says there are expectations that registered nurses be culturally competent and clinically competent “but time and time again clinical competency outweighs the need for nurses to be seen to be culturally appropriate.” She says, as an example, that nurses must undergo ongoing professional development to be deemed clinically competent, whereas it is accepted that nurses will be still culturally competent after attending, though not necessarily participating in, a Treaty of Waitangi workshop five years previously. “It’s almost like a default that we sanction ignorance around working in Aotearoa and the unique relationship we have as tangata whenua.”

Mentoring and supervision

Having strong support mechanisms for Māori and Pacific nurses in hospitals and other organisations is also seen as key to recruiting and retaining nurses.

Nuku says strong mentoring programmes are needed not only for new graduates but also for Māori nurses throughout the continuum of nursing until retirement.

McHaffie also recommends that her graduates find a cultural advisor or mentor from whom they can obtain advice or talk to about situations that may arise. Nurses can also seek support from the Māori health units that are often within larger DHBs.

What is needed and wanted by many Māori nurses, believes Stewart, is cultural supervision, just as clinical supervision is offered to nurses in the mental health sector, to support best practice.

Networking with other Māori health professionals also emerged as an important coping strategy for stress, says Stewart,
but this was often seen by non-Māori managers as a social activity, rather than a chance to share ideas, download and support each other. “There seems to be a lack of understanding about what organisational conditions need to exist in order for Māori nurses and other health professionals to be most effective at their job.”

Likewise, Pacific Nursing head Eseta Finau says one of the most important roles of the country’s various Pacific nurses associations – such as the umbrella NZNO Pacific Nursing Section, the Samoan Nurses Association, the Tongan Nurses Association (which she also leads), and other Pacific nursing groups – is the support and mentoring they provide for members.

But when she invites nurses to join the NZNO Pacific Nursing Section and help to train a new generation of leaders, she says employers often won’t allow them to attend in work time. “Yet this is all towards the wellbeing and the future of our Pacific people in the communities that we live in.” With many Pacific nurses being the breadwinners for their family, it is a big ask to take a day off to attend a meeting, but committed nurses will use precious annual leave to attend, which Finau says is “just not fair”.

She says one way to deal with stress and burnout is by supporting people to be trained to fill leadership positions such as in the PNS to share the load.

Learning when to say ‘no’

An important skill for preventing burnout is the art of when to say ‘no’. Culturally, this is not always simple for Māori and Pacific nurses.

Stewart says it is actually harder for Māori and Pacific nurses to say ‘no’ to their cultural communities then it is to say ‘no’ to people at work.

Finau acknowledges saying ‘no’ can be an issue for Pacific nurses. “Some of us are just too polite and say ‘yeah’, ‘yeah’, ‘yeah’ and don’t say ‘no’ to anything. And commit and commit and you can tell they are over their limits. It’s a cultural thing – just trying to be nice and serve others rather than thinking about what you can do and what you can cope with.”

The result is that nurses can learn to cope and over-cope, but Finau says she can say ‘no’. “I know when to say ‘no’ and tell them when this is enough and when things are rubbish.”

Vaka says he used to over-commit to a lot of community projects and, combined with his PhD study, this left too little space for family time. “No wonder my wife would call my PhD the ‘other woman’,” laughs Vaka. He realised he had to be very selective in what extra commitments he said ‘yes’ to and now, unless he believes his expertise in health and research is going to be well used, he will recommend another person. But it is still not easy.

“At the moment I am still struggling to say ‘no’ to people. But I think I know now how to say ‘no’ nicely,” laughs Vaka. “And I think for us Pacific people we need to know when to say ‘no’, as we need to reassess when we have enough on our plate already if we want to deliver a good quality service [to our work and our community]. Don’t be scared of saying ‘no’.”

Stewart agrees that it helps if nurses prioritise which goals are most important to them and decide how to make the best use of their time and expertise to meet those goals. This includes being aware of their own capabilities and when they are at risk of burnout “rather than just blindly saying ‘yes’ to everything”.

Conclusion

With its small numbers of nurses and high population needs, the Māori and Pacific health workforce is unfortunately at real and ongoing risk of burnout. Helping the existing workforce look after itself seems essential if that workforce is to have the rapid growth required to meet government targets and community needs.

One part of the equation is for funders and employers to keep working at better supporting and fostering this scant workforce. Another may be for communities to be realistic in the expectations they place on their nursing members. The last is for nurses themselves to do their best to look after themselves (see sidebar for some ideas).

“Nurses are no strangers to reflective practice – it is just a matter of reflecting on themselves rather than their work,” says Stewart.

“The reality is that if we aren’t looking after ourselves, how can we do our best to look after our communities? The best way we can serve our communities is to make sure we are well ourselves.”

Pacific nursing students: walking the talk

The nursing lecturer, co-ordinator for year two of Whitireia Community Polytechnic’s Bachelor of Nursing (Pacific), decided she had to start somewhere to make a difference and a good place to begin was with herself and her students.

Her philosophy is to try and build a healthy lifestyle into everyday living to stop the real risk nurses face of being so busy looking after others that they forget to look after themselves.

So her personal journey has included giving up her car so she walks to work most days, her teenage kids are more active and the temptation is removed to drive to get takeaways after a busy day.

Her teaching journey includes supporting her very committed students to build an understanding of other’s health needs by turning it around and looking at their own health needs first.

“The statistics tell us that Pacific people are highly represented in rates of obesity and chronic disease and you can bet that that statistic is represented in the classroom too.” The pressures of study can also impact negatively on health with students working long hours and filling up on cheap hot chips from the student café.

Empowering students

Tasi says she tries to takes an empowering holistic approach so sets aside time in the study week for students to gather in small groups to set a simple personal health goal for the year; examine the evidence behind it, identify the challenges (including being time and money poor students) and support each other through the year to meet that goal; be it quitting smoking or eating more healthily.

She backs this in the classroom by teaching the science behind healthy lifestyle changes that can reduce the risk of chronic diseases like diabetes and heart disease.

For example, when she does a session on acids, alkalis and blood pH she makes students record all they ate in the previous three days. They arrive in the classroom to find acidic written up on one side of the white board and alkali on the other and she gets them to write-down each serving of vegetables, chips, fruit, pie, alcohol, soft drink or cereal they ate or drank on a Post-it note and stick them on the appropriate side of the board.

She says there is a lot of laughter during the exercise but quickly the acidic side of the board fills up giving students a graphic depiction and reality check that their diet is not okay. “Over the term students report back that they’ve changed a lot in their family’s diet and also saved money in some cases.”

Tasi’s aim is to empower Pacific people to reverse unhealthy lifestyle patterns, caused by shifting to New Zealand, as part of a nursing curriculum that emphasises Pacific nurses understanding who they are, where they came from and equipping them with the knowledge to rebuild a healthy lifestyle one step at time; starting with their own family, their friends and, in time, the community they care for as nurses.

Advice on stress management

Learn to recognise and notice your own symptoms of stress.

Find out what resources are available either within or outside your organisation to prevent, reduce or manage that stress.
Try:

workplace exercise or mindfulness classes

EAP (employee assistance programmes) that may offer counselling.

Look to culturally relevant models of health as a framework for managing your stress: i.e. Professor Mason Durie’s Māori health assessment framework, known as Te Whare Tapa Whā (1982) and the Pacific health and wellbeing model Fonofale (2009), developed by Fuimaono Karl Pulotu-Endemann.
Both of these models have four elements in common:

Mental health: mindfulness or meditation or time out to simply read or go for a quiet walk.

Spiritual health: could be church or prayer or taking part in cultural activities such as kapahaka and cultural festivals.

Social health: connecting with your whānau/family and with other communities you are part of (be it your church or your touch rugby team) to help nurture and re-energise you.

Remember that giving is good, but over-giving is not good and can impact on your own health, which is not good for the community you serve.

Be aware of your limitations.

Set priorities for what goals you value most and be strategic in how you allocate your time and expertise to best support those goals.

Learn when and how to say ‘no’ in a way you are comfortable with.

See related articles in this edition on general stress management, being work-fit and looking after yourself.

Barriers and enhancers sidebar table

Barriers to retention of Māori in the health and disability sector*

In mainstream roles, expected to be expert in and deal with Māori matters

65%

Māori cultural competencies are not valued

64%

Dual responsibilities to employer and Māori communities

58%

Lack of or low levels of Māori cultural competence of colleagues

58%

Limited or no access to Māori cultural competency training

51%

Limited or no access to Māori cultural support/supervision

48%

Racism and/or discrimination in the workplace

39%

Isolation from other Māori colleagues

33%

Retention enhancers for Māori in the health and disability sector

Making a difference to Māori health

92%

Making a difference for my iwi/hapū

89%

Being a role model for Māori

80%

Ability to network with other Māori in the profession

83%

Strengthening Māori presence in the health sector

92%

Being able to work with Māori people

89%

Māori practice models and approaches valued

81%

Opportunities to work in Māori settings

80%

Source: Participants’ ratings of importance of barriers as either ‘quite a lot’ or ‘major importance’ in research carried out for RATIMA et al. (2007), Rauringa Raupa, Ministry of Health. (Republished in Lisa Stewart’s ‘Māori Occupational Stress’ thesis.)

Stats

Māori

As at 31 March last year, 3,510 practising nurses – comprising 15 nurse practitioners, 3,245 registered nurses and 250 enrolled nurses – identified as Māori. This represents seven per cent of the total nursing workforce.

In the 2013 census, Māori comprised 15.6 per cent of the total New Zealand population and were younger overall than the non-Māori population (a third were aged under 15).

Pacific

There are more than 40 different Pacific ethnic groups in New Zealand, each with its own culture, language and history.

As at 31 March last year, 1,733 practising nurses – comprising three nurse practitioners, 1,628 registered nurses and 102 enrolled nurses – identified with at least one Pacific ethnic group. This represents three per cent of the total nursing workforce.

In the 2013 census, people identifying as Pacific comprised 7.4 per cent of the total New Zealand population and were also younger, on average, than the total population, with more than a third of Pacific people aged under 15 (compared with
z20 per cent of the total population).

Twenty-five per cent of Pacific nurses (425) were trained overseas – the majority in a Pacific nation.

Health Statistics

Ministry of Health statistics show that Māori have higher rates than non-Māori for many health conditions and chronic diseases, including cancer, diabetes, cardiovascular disease, chronic pain, arthritis and asthma. About two out of five (40 per cent) Māori are obese, compared with around a third (33 per cent) of the total population.

Ministry of Health statistics show Pacific people have a higher burden of chronic disease, such as diabetes, ischaemic heart disease and stroke. Two out of three Pacific adults are obese, compared with a third of the total population and the diagnosis rate for diabetes is approximately three times the rate for the total population.

Socioeconomic determinants of health (such as unemployment, income, education and housing), plus lifestyle behaviours and cultural, historical and other factors all impact on the health risks and unmet health needs of Māori and Pacific people.

Enough is enough

Pay equity wanted for Māori and iwi health provider nurses

Back in 1908, one of the country’s first Māori registered nurses and midwives, Akenehi Hei*, struggled to get the government to pay for her work. (See her story below.)

More than a century later, nurses working for Māori and iwi health providers are still struggling with pay equity issues, says Kerri Nuku, kaiwhakahaere of Te Rūnanga o Aotearoa NZNO. Nuku says the pay gap between iwi nurses and their district health board counterparts has now got to the point that she knows of iwi nurses taking on extra jobs or contracts to make up for the low wages and to ensure a reasonable standard of living for their families.

The journey for pay equity for these nurses began back in 2006. It followed the ‘pay jolt’ ratified in 2005 for district health board nurses, which initially saw the pay gap widen between all non-DHB nurses and their DHB colleagues. A further pay gap subsequently emerged between nurses employed by Māori-led healthcare organisations and their counterparts employed by primary health organisation (PHO) funded general practices. At the crux of the issue is a government funding model for Māori and iwi health providers that differs from that of a typical neighbourhood general practice.

An 11,000-plus petition was presented to Parliament back in July 2008, pointing out the inequity and calling for the Government to work with NZNO and Māori and iwi PHC employers so that pay equity could be funded and delivered to their nurses and other health professionals.

In 2009, in response to the petition and other evidence presented, the Health Select Committee recommended to Parliament that a working group look further into the petition issues – including recruitment and retention issues for the providers that deliver targeted services to Māori communities – and report back in six months. But Nuku says the Committee’s recommendation was vetoed by the Government and the working group never formed.

She says there is also increasing frustration that health workforce projects keep setting Māori health workforce targets to meet health needs but as yet New Zealand still doesn’t have a single data repository showing what the current Māori workforce looks like, let alone addressing pay equity issues impacting on retention and recruitment of that workforce.

Nuku says after a decade of unsuccessfully petitioning, lobbying and negotiating for more data and improved funding so Māori and iwi health providers can close the ever-widening pay gap, the rūnanga have said “enough is enough”.

“How do we shine the spotlight on this discriminatory practice that has been going on for way too long?”

There are documents such as 2012’s Thriving as Māori 2030, which says health services need to “at least triple” the Māori workforce by 2030 to reflect the communities they serve, and the tripartite Nursing Workforce Programme, which late last year set 2028 as the date that the percentage of Māori nurses needs to match the percentage of Māori in the population. But Nuku says that initiatives to date have done little to grow the Māori proportion of the nursing workforce, which has been basically static since the 1990s.

“So we have been feeling quite aggrieved for a wee while,” she says. But after years of being wary of speaking out, she says rūnanga members are readying themselves for a ‘big year’ in 2016 and to start challenging the status quo. She says they are now viewing pay parity for Māori and iwi providers, and the lack of information on Māori health workforce data, as human rights issues. To this end, NZNO has written to the Universal Periodic Review (the United Nation’s Human Rights Council process that reviews the human rights situations of all 193 UN member states) to express its concerns about the issues and has also raised its concerns with New Zealand’s Equal Employment Opportunities (EEO) Commissioner, Dr Jackie Blue.

Pioneering nurse Akenehi Hei

In 1901 Akenehi Hei began a basic nursing skills programme intended to make her an “efficient preacher of the gospel of health” when she returned to her village as a “good, useful wife and mother”. In 1905 the scheme was extended to offer full nurse training and the still-unmarried Hei qualified as a registered nurse in mid-1908. She quickly completed her midwifery training in the same year in readiness to be part of a 1907 Public Health Department scheme to employ Māori district nurses (working in public hospitals was not envisaged or encouraged for the first Māori nurses.)

But by 1908 there were still no government funds allocated to pay for Māori district nurses and it wasn’t until June 1909 that she was offered a two-month post nursing in a Northland typhoid epidemic. After that it took several more months until she was finally offered another post in New Plymouth. Tragically, she succumbed to typhoid herself in late 1910 after returning to Gisborne to nurse family members ill with typhoid.

Her biography in Te Ara – The Encyclopedia of New Zealand states she not only had to deal with institutional racism – her postings were seen as a test case “to see how these Māori nurses act” – but also with little support from a department which was concerned with minimising costs and was not fully committed to Māori health work.

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